Systems, devices, and methods for securing tissue using a suture having one or more protrusions

ABSTRACT

Systems, devices, and methods are provided for securing soft tissue to bone. One exemplary embodiment of a surgical repair construct includes an anchor, a filament having a snare on one end and a collapsible loop on another end, and a suture having a plurality of stationary protrusions. The suture is configured to be coupled to detached tissue and have its ends passed through an opening in the snare. The snare can be collapsed around the suture so at least one of the protrusions is proximal of the collapsed snare. The anchor can be disposed in bone and the filament coupled thereto. Accordingly, collapsing the snare around the suture couples the tissue to bone, and applying tension to a tensioning limb of the filament can collapse the loop to incrementally tighten and secure the tissue to bone. Other exemplary systems, devices, and methods for use with tissue repair are also provided.

CROSS REFERENCE TO RELATED APPLICATIONS

The present application is a divisional of U.S. patent application Ser.No. 13/465,362, filed May 7, 2012, and entitled “SYSTEMS, DEVICES, ANDMETHODS FOR SECURING TISSUE USING A SUTURE HAVING ONE OR MOREPROTRUSIONS,” which is hereby incorporated by reference in its entirety.

FIELD

The present disclosure relates to systems, devices, and methods forsecuring soft tissue to bone, and more particularly relates to securingsoft tissue using a suture having one or more protrusions formed thereonwhile minimizing or eliminating the tying of knots to tension and securethe tissue.

BACKGROUND

A common injury, especially among athletes and people of advancing age,is the complete or partial detachment of tendons, ligaments, or othersoft tissues from bone. Tissue detachment may occur during a fall, byoverexertion, or for a variety of other reasons. Surgical interventionis often needed, particularly when tissue is completely detached fromits associated bone. Currently available devices for tissue attachmentinclude screws, staples, suture anchors, and tacks. Currently availabledevices for patients of advancing age can be particularly insufficientdue to soft and weak bones leading to inadequate suture-to-anchorfixation.

Arthroscopic knot tying is commonly practiced in shoulder rotator cuffand instability procedures. Typically, an anchor loaded with suture isfirst attached to bone. The suture is normally slidably attached to theanchor through an eyelet or around a post, such that a single length ofsuture has two free limbs. One limb of the suture is passed through softtissue to be repaired such as a tendon or labrum. The two ends of thesuture are then tied to each other, thereby capturing the soft tissue ina loop with the anchor. Upon tightening the loop, the soft tissue isapproximated to the bone via the anchor.

Surgeons typically tie the suture ends using a surgical sliding knotsuch as the Tennessee Slider or Duncan Loop. After advancing the knotdistally to tighten the loop, a number of additional half hitches orother knots are tied in an effort to secure the new location of thesliding knot. The additional knots are needed because a conventionalsliding knot used in current repair constructs does not provide thenecessary protection against loosening or slippage, especially whentension is placed primarily on the limbs of the loop. The generallyaccepted practice is to follow the sliding knot with at least threereversed half hitches on alternating posts of the suture.

Before one or more half hitches or other knots can be added to thesliding knot, however, there exists a potential for the sliding knot toslip, that is, for the loop to enlarge as the tissue places tension onthe loop. This has been referred to as “loop security” and canreportedly occur even in the hands of very experienced surgeons.Sometimes, even fully-tied knots may slip. In addition to this “loopsecurity” problem, conventional knots typically have an overall sizethat can be obstructive or intrusive, especially in tight joints, whichmay damage cartilage or other tissue by abrasion with the knot.

Suture anchor systems with sliding and locking knots for repairing tornor damaged tissue include U.S. Pat. No. 6,767,037 by Wenstrom, Jr. Othersuture anchor systems suited especially for meniscal repair aredisclosed in U.S. Pat. No. 7,390,332 by Selvitelli et al. and areutilized in the OmniSpan™ meniscal repair system commercially availablefrom DePuy Mitek Inc., 325 Paramount Drive, Raynham, Mass. 02767.Screw-type anchors normally require anchor attachment before operatingsutures, which can lead to challenges related to the connection betweenthe suture and the tissue.

There are a number of suture implant systems which proclaim to be“knotless,” that is, to not require a surgeon to tie a knot duringsurgery. Many such systems control tension on tissue by the depth towhich an anchor is driven into bone. U.S. Pat. Nos. 5,782,864 and7,381,213 by Lizardi disclose certain types of suture anchors thatcapture a fixed-length loop of suture. Adjustable loop knotless anchorassemblies utilizing an anchor element inserted into a sleeve aredescribed by Thal in U.S. Pat. Nos. 5,569,306 and 6,045,574 and in U.S.Patent Application Publication No. 2009/0138042. Other systems havingclamps or other locking mechanisms include U.S. Pat. No. 5,702,397 byGoble et al. and U.S. Patent Application Publication No. 2008/0091237 bySchwartz et al. Present, so-called “knotless” designs, however,generally suffer from inadequate suture-to-anchor fixation and/orinadequate anchor-to-bone fixation, among other deficiencies.

It is therefore desirable to provide systems, devices, and methods foruse in soft tissue repair that are robust, strong, and improve “loopsecurity,” yet minimize or eliminate the number and size of knots to betied by a surgeon, particularly during arthroscopic repair procedures.

SUMMARY

Systems, devices, and methods are generally provided for securing softtissue to bone. In one exemplary embodiment a surgical repair constructincludes an anchor, a filament having a collapsible snare formed on oneend thereof and a collapsible loop at a second end thereof, and a suturehaving a plurality of stationary protrusions formed thereon in aspaced-apart arrangement. The anchor can include a filament engagementfeature and can be capable of being fixated in bone. The filament andthe suture are both capable of being passed through soft tissue to berepaired. An opening of the filament's snare can be configured toreceive the suture such that the snare is slidable with respect to thesuture and collapsible around the suture. The filament's collapsibleloop can be coupled to the anchor's filament engagement feature, and theloop can include a sliding knot with a tensioning limb extendingtherefrom. The tensioning limb can be effective to collapse thecollapsible loop independent of the snare. Further, the collapsible loopcan be capable of being tightened incrementally to secure the softtissue to bone.

The snare can have a variety of configurations and can be made in anumber of different ways. In some embodiments, the snare can beconfigured by passing a terminal end of the filament through an adjacentportion of the filament. The terminal end can include a protrusion thatmaintains the terminal end within the portion of the filament throughwhich it is disposed. In some other embodiments, the snare can beconfigured by a second sliding knot that is effective to collapse thesnare. In still other embodiments, the snare can include a coaxialsliding neck that is effective to collapse the snare. Further, aflexible member can be removably placed in a portion of the snare toprevent unintentional collapse of the snare, and when the snare includesa coaxial sliding neck, the flexible member can be removably disposedtherethrough to immobilize the coaxial sliding neck. The filament can bea cannulated surgical filament or a braided suture filament. Further, inembodiments that include a flexible member, the flexible member can beformed of a second filament. A thickness of the second filament can bein the range of about 25 gauge to about 40 gauge, while a thickness ofeither or both of the filament that forms the collapsible loop and thecollapsible snare can be in the range of about 20 gauge to about 34gauge. The diameter of the protrusions of the suture can be in the rangeof about 0.5 millimeters to about 2 millimeters.

In one exemplary embodiment of a surgical repair method, the methodincludes passing a first end of a suture having formed thereon aplurality of stationary protrusions through and/or into tissue. Thefirst end of the suture can be passed through the tissue such that firstand second limbs of the suture extend from the first side of the tissue.The suture can be arranged in the tissue such that at least one of theprotrusions is disposed adjacent to at least one of the first and secondsides of the tissue. In one embodiment at least one protrusion isdisposed adjacent to the first side of the tissue. The method can alsoinclude inserting an anchor into bone in proximity to the detached softtissue. The anchor can have a filament engagement feature to which afilament is attached, and the filament can have a collapsible snareformed on one end and a collapsible loop at its second end, thecollapsible loop being coupled to the filament engagement feature. Thecollapsible loop can include a sliding knot with a tensioning limb thatextends therefrom, and the tensioning limb can be effective to collapsethe collapsible loop independent of the snare. The method can furtherinclude inserting the first and second limbs of the suture through anopening formed in the snare, sliding the snare distally towards thetissue and distally past at least one protrusion disposed on the firstside of the tissue, collapsing the snare around the first and secondlimbs of the suture, and pulling the snare towards the anchor byshortening the collapsible loop and thus drawing the tissue intoproximity with the bone.

In some embodiments the step of pulling the snare towards the anchor byshortening the collapsible loop can include tensioning the tensioninglimb. In such embodiments the snare can be advanced in an incrementalfashion without slackening of the filament. The suture can include atleast four protrusions. In some embodiments the snare can be positionedbetween at least one protrusion and the tissue, while in some otherembodiments the snare can be positioned between at least two protrusionsand the tissue. Optionally, a flexible member can be disposed in aportion of the snare to prevent unintentional collapse thereof. In suchembodiments the flexible member can be removed from the snare prior tocollapsing the snare. The methods provided for herein can be performedwithout tying a knot.

BRIEF DESCRIPTION OF DRAWINGS

This invention will be more fully understood from the following detaileddescription taken in conjunction with the accompanying drawings, inwhich:

FIG. 1 is schematic view of one exemplary embodiment of a surgicalrepair construct disposed at a surgical site;

FIG. 2 is a schematic view of one exemplary embodiment of a filamentcoupled to an anchor for use as part of a surgical repair construct;

FIG. 3 is a close-up view of a portion of the filament of FIG. 2,illustrating the formation of a snare using the filament;

FIG. 4 is a schematic view of a filament coupled to an anchor from thesurgical repair construct of FIG. 1;

FIGS. 5A-5D are sequential views of one exemplary embodiment for forminga snare from a filament in which the snare has a coaxial sliding neck;

FIG. 6 is a schematic view of one exemplary embodiment of a snare formedfrom a filament and a flexible member in which the snare has a coaxialsliding neck and the flexible member is disposed through the snare;

FIG. 7A is a schematic view of another exemplary embodiment of a snareformed from a filament and a flexible member in which the snare has acoaxial sliding neck, this view illustrating how the flexible member canbe disposed through the neck and the snare;

FIG. 7B is a schematic view of the snare and flexible member of FIG. 7A,illustrating the flexible member disposed through the neck and thesnare;

FIG. 8 is a schematic view of a suture from the surgical repairconstruct of FIG. 1; and

FIGS. 9A-9E are sequential views of one exemplary embodiment for usingthe surgical repair construct of FIG. 1 to secure tissue to bone.

DETAILED DESCRIPTION

Certain exemplary embodiments will now be described to provide anoverall understanding of the principles of the structure, function,manufacture, and use of the devices and methods disclosed herein. One ormore examples of these embodiments are illustrated in the accompanyingdrawings. Those skilled in the art will understand that the devices andmethods specifically described herein and illustrated in theaccompanying drawings are non-limiting exemplary embodiments and thatthe scope of the present invention is defined solely by the claims. Thefeatures illustrated or described in connection with one exemplaryembodiment may be combined with the features of other embodiments. Suchmodifications and variations are intended to be included within thescope of the present invention. Further, in the present disclosure,like-numbered components of the embodiments generally have similarfeatures, and thus within a particular embodiment each feature of eachlike-numbered component is not necessarily fully elaborated upon.Additionally, to the extent that linear or circular dimensions are usedin the description of the disclosed systems, devices, and methods, suchdimensions are not intended to limit the types of shapes that can beused in conjunction with such systems, devices, and methods. A personskilled in the art will recognize that an equivalent to such linear andcircular dimensions can easily be determined for any geometric shape.Sizes and shapes of the systems and devices, and the components thereof,can depend at least on the anatomy of the subject in which the systemsand devices will be used, the size and shape of components with whichthe systems and devices will be used, and the methods and procedures inwhich the systems and devices will be used.

The figures provided herein are not necessarily to scale. Still further,to the extent arrows are used to describe a direction a component can betensioned or pulled, these arrows are illustrative and in no way limitthe direction the respective component can be moved. A person skilled inthe art will recognize other ways and directions for creating thedesired result. Additionally, a number of terms may be used throughoutthe disclosure interchangeably but will be understood by a personskilled in the art.

Systems, devices, and methods for soft tissue repair are generallyprovided and they generally involve the use of surgical filaments andsutures that are configured in a variety of manners to minimize and/oreliminate the tying of knots during a surgical procedure. The systemsand devices described herein provide superior strength for use in anumber of different surgical procedures, such as rotator cuff andinstability repair procedures and other types of tendon and tissuerepair procedures. The systems and devices provided herein also allowfor both improved and new procedures for soft tissue repair. Forexample, the systems and devices provided herein can be used to advancetissue towards bone in an incremental fashion without the constructbacklashing. Reducing and/or eliminating backlashing during advancementcan prevent the size of the collapsible loop from increasing and preventthe tissue from moving away from the bone and/or not being held tightlyin place with respect to the bone due to backlashing. Additionally, thesystems and devices allow a surgeon to secure a location of the tissuewithout tying a knot during the procedure.

As shown by one exemplary embodiment of a surgical repair construct 10in FIG. 1, the constructs of the present disclosure generally include afilament 20 that forms a snare 50 at a first end 22 thereof and acollapsible loop 30 at a second end 24 thereof, a suture 70 having oneor more stationary protrusions 72 formed therein, and an anchor 90coupled to the collapsible loop 30, for instance at an engagementfeature 92 of the anchor 90. In the illustrated embodiment, the anchor90 is disposed in bone 100, the suture 70 is passed through soft tissue,for example tendon 102, and the snare 50 is slidable with respect to thesuture 70 and collapsed around a portion of the suture 70 to couple thebone 100 and tendon 102 via the surgical repair construct 10. As will bedescribed in greater detail below, the snare 50 can begin outside of thebody and be moved distally (e.g., towards the bone 100) such that it isdistal of at least one of the protrusions 72. The snare 50 cansubsequently be collapsed such that the protrusions 72 prevent the snare50 from backlashing in a proximal direction (e.g., away from the bone100), which would allow the tissue to move away from the bone. Thefilament 20 can further include a sliding knot 36 at a first end 32 ofthe loop 30, which can be moved distally towards a second end 34 of theloop 30 to collapse a size of an opening 38 formed by the loop 30,thereby applying a force to draw the tendon 102 towards the bone 100. Acollapsible tail or tensioning limb 40 can extend from the sliding knot36 and can be operable to move the sliding knot 36 towards the secondend 34 in a ratchet-like or incremental manner to secure the tendon 102to the bone 100. Movement, of the snare 50, including collapsing thesnare 50, and movement of the collapsible loop 30, including bytensioning the tensioning limb 40, can be independent of each other.

Filaments for use in a surgical repair construct can have a variety ofconfigurations, some of which are described in greater detail below.Generally filaments have a portion for grasping a separate suturecoupled to tissue, illustrated herein as a snare, and a portion,illustrated herein as a collapsible loop, that is coupled to bone and towhich tension can be applied to draw the tissue towards bone. Inoperation, grasping the separate suture couples the tissue to thefilament and collapsing the loop towards the bone draws the tissuetowards the bone.

FIG. 2 provides one exemplary embodiment of a filament 120 for use aspart of a surgical repair construct. A first end 122 of the filament 120can include a snare 150 that is configured to collapse under tension, asecond end 124 of the filament 120 can include a collapsible loop 130that is configured to collapse under tension, independent of the snare150, and a neck 123 can extend between the first and second ends 122,124. The filament 120 having both a snare 150 and a collapsible loop 130can be referred to as a snare assembly.

The snare 150 can be formed in a variety of ways known to those skilledin the art, some of which are discussed in greater detail below. In theillustrated embodiment the snare 150 is formed by passing a portion ofthe filament 120 through itself. Further, a protrusion 129 can be formedat a terminal end 128 of the filament 120, proximate to the snare 150,to prevent pull-through and to resist fraying, particularly if thefilament 120 is a braided filament. The protrusion 129 can bepre-formed, or it can be formed by a surgeon, for instance by tying ahalf-hitch or other simple knot.

FIG. 3 illustrates one of the many ways the snare 150 can be formed. Asshown, a leading end 126 of the filament 120 can be passed through anopening 127 of the filament 120 to form a collapsible opening 152 of thesnare 150. The opening 127 can be pre-formed and collapsible, oralternatively, it can be part of the construct of the filament 120, suchas an opening due to the filament 120 being braided. The leading end 126can be used to form the other portions of the filament 120, includingthe collapsible loop 130, a sliding knot 136, and a tensioning limb 140,which are described in greater detail below, for instance by forming theloop 130 and the sliding knot 136 on the tensioning limb 140. In thisarrangement, any tension applied on the neck 123, such as by pulling thetensioning limb 140, not only collapses the snare 150 to strangulateobjects passing therethrough, but also binds the portion of the filament120 passing through the opening 127 upon itself. In other arrangements,a half-hitch or other simple knot can be tied adjacent to the opening,and the filament 120 can be looped through that simple knot.

The loop 130 can likewise be formed in a variety of ways known to thoseskilled in the art, some of which are discussed in greater detail below.In the illustrated embodiment of FIG. 2, the loop 130 has first andsecond ends 132, 134, with a sliding knot 136 formed at the first end132. As shown, the second end 134 can be slidably coupled to an anchor190, for instance at an engagement feature 192 thereof, such as a saddleor post. While in the illustrated embodiment the engagement feature 192is located at a distal end 190 d of the anchor 190, it can be located inany part of the anchor 190 and it allows the filament 120 to be slidablyengaged with the anchor 190.

The collapsible loop 130 can be expanded and collapsed as desired by thesliding knot 136. Accordingly, when the loop 130 is coupled to tissue,for instance by having a suture disposed through the snare 150 of thefilament 120 that forms the loop 130, collapsing the loop 130 creates aforce that draws the tissue towards a desired location. As shown in FIG.2, as the sliding knot 136 is moved towards the second end 134, the loop130 collapses, and as the knot 136 is moved away from the second end134, the size of an opening 138 of the loop 130 increases. The slidingknot 136 can be formed in a variety of ways using a variety oftechniques well known to those skilled in the art. Non-limiting examplesof the types of knots that can be used as the loop's sliding knotinclude a Buntline Hitch, a Tennessee Slider, a Duncan Loop, a Hangman'sNoose, and a loop having a coaxial sliding neck. The type of knotselected may affect the manner in which the loop 130 can be collapsed,and a person having skill in the art will recognize how to collapse theloop based on the type of knot used.

As shown in FIG. 2, the loop 130 can also have a collapsible tail ortensioning limb 140 that extends from the sliding knot 136. Thetensioning limb 140 can be a terminal end of a limb of the filament 120used to form the sliding knot 136 that completes the collapsible loop130. The tensioning limb 140 can be operable to tension and collapse theloop 130 by moving the sliding knot 136 towards the loop second end 134.More particularly, applying tension to the tensioning limb 140 inapproximately a direction A can cause the knot 136 to slide distallytowards the second end 134. As a result, the sliding knot 136 can movein a ratchet-like or incremental fashion such that the knot 136 movestowards the second end 134 with little or no backlashing, which in turnminimizes or prevents the opening 138 of the collapsible loop 130 fromincreasing in size. When tension is not applied, the location of thesliding knot 136 remains substantially fixed, and further tensioning ofthe tensioning limb 140 can cause further distal movement of the knot136 until either the tension is released or an obstruction precludesfurther distal movement of the knot 136. The self-locking capabilitiesprovided by this sliding knot 136 that results from the overallformation of a surgical repair construct including the filament 120 arebeneficial at least because of the ability to incrementally advance theknot 136 with minimal or no backlashing. Still further, in someembodiments a second, stationary tail or tail can also be formed and canbe used, for example, to assist in threading the filament throughtissue, providing additional strength to the repair, and/or performingvarious surgical procedures, such as double row procedures

With reference to FIG. 3, an example of steps for manufacturing thesnare assembly formed by the filament 120 is as follows. The protrusion129 can be formed at the terminal end 128 by tying a knot and a tail ofa terminal end thereof can be trimmed. The leading end 126 can be loopedand passed through itself at the opening 127, in close proximity to theprotrusion 129, to form the opening 152 in the snare 150. Alternatively,a second half-hitch can be tied in close proximity to the protrusion 129and the leading end 126 can be passed through the second half-hitch toform the opening 152 in the snare 150. A flexible member, such as afilament or suture (discussed in greater detail below with respect toFIGS. 6, 7A, and 7B), or other objects, including but not limited tothin mandrel or pin, can be placed through the snare 150 to maintainpatency. The sliding knot 136, such as a Buntline Hitch, can be tied inclose proximity to the snare 150 and the filament 120 can be placed insliding engagement with an engagement feature of an anchor. The slidingknot 136 can be subsequently dressed or finalized as desired, includingin manners described herein.

FIG. 4 provides another exemplary embodiment of a filament 120′ for useas part of a surgical repair construct. Similar to the filament 120, afirst end 122′ of the filament 120′ can include a snare 150′ having anopening 152′ that is configured to collapse under tension, a second end124′ of the filament 120′ can include a collapsible loop 130′ that isconfigured to collapse under tension, independent of the snare 150′, anda neck 123′ can extend between the first and second ends 122′, 124′. Thefilament 120′ having both a snare 150′ and a collapsible loop 130′ canbe referred to as a snare assembly.

The snare 150′ can be formed in a variety of ways known to those skilledin the art, some of which are discussed in greater detail below. In theillustrated embodiment the snare 150′ is formed by way of a sliding knot156′, such as, by way of non-limiting examples, a Buntline Hitch, aTennessee Slider, a Duncan Loop, a Hangman's Noose, and a loop having acoaxial sliding neck. Although the type of sliding knot will affect therelative movement of the knot 156′ and the filament 120′ with respect tothe direction either is moved to expand or collapse the snare 150′, asdescribed herein, unless otherwise designated, a knot used to form asnare is movable away from the second end 124′ of the filament 120′,i.e., away from the collapsible loop 130′, to collapse the snare 150′and towards the second end 124′, i.e., towards the collapsible loop130′, to increase a size of the snare 150′. A person skilled in the artwould be able to adapt the teachings herein based on the type of slidingknot used in conjunction with the snare 150′.

FIGS. 5A-5D illustrate one of the many ways the snare 150′ can beformed. As shown, the snare 150′ is formed from a bifurcated suturefilament having a tubular portion 153′ with a core removed therefrom toform a cannulated portion 154′ and first and second terminal limbs 156′,158′. As shown in FIG. 5B, the terminal limbs 156′, 158′ can be curledback towards the tubular portion 153′ to form a loop having an opening152′ that defines the snare 150′. As shown in FIG. 5C, a bore 160′ canbe formed on a side of the tubular portion 153′ and the terminal limbs156′, 158′ can be placed into the cannulated tubular portion 154′through the bore 160′. Ends of the terminal limbs 156′, 158′ can be fedthrough the cannulated portion 154′, and as shown in FIG. 5D, theterminal limbs 156′, 158′ can be pulled distally (direction B in FIG.5D) through the tubular portion 153′ such that the tubular portion 153′is fed through itself and a coaxial sliding neck 155′ that can slidewith respect to the tubular portion 153′ of the filament is formed.Accordingly, the snare 150′ can be collapsed by tensioning the limbs156′, 158′ and/or coaxial sliding neck 155′ in approximately a firstdirection B, and the snare 150′ can be expanded by applying a force tothe snare 150′ in approximately a second, opposite direction C, whichpulls the limbs 156′, 158′ and the coaxial sliding neck 155′ towards thesnare 150′. Passing the filament through itself to form a coaxialsliding neck allows the filament to have a low profile that minimizesthe amount of space the construct consumes in the body and thatminimizes and/or eliminates trauma associated with passing the filamentthrough tissue.

The loop 130′ can likewise be formed in a variety of ways known to thoseskilled in the art, some of which are discussed in greater detail below.In the illustrated embodiment of FIG. 4, the loop 130′ has first andsecond ends 132′, 134′ with a sliding knot 136′ formed at the first end132′. As shown, the second end 134′ can be slidably coupled to an anchor190′, for instance at an engagement feature 192′ thereof, such as asaddle or post. While in the illustrated embodiment the engagementfeature 192′ is located at a distal end 190 d′ of the anchor 190′, itcan be located in any part of the anchor 190′ and allows the filament120′ to be slidably engaged with the anchor 190′.

The collapsible loop 130′ can be expanded and collapsed as desired bythe sliding knot 136′ in a manner similar to as described with respectto the sliding knot 136 of the loop 130. Further, as shown in FIG. 4,the loop 130′ can include a collapsible tail or tensioning limb 140′that extends from the sliding knot 136′ and can operate in a mannersimilar to as described with respect to the tensioning limb 140. Thus,the loop 130′ of the filament 120′ can move in a ratchet-like orincremental fashion such that the knot 136′ moves towards the second end134′ with little or no backlashing, which in turn minimizes or preventsthe opening of the collapsible loop 130′ from increasing in size. Stillfurther, in some embodiments a second, stationary tail or tail can alsobe formed and used in a manner similar to as described with respect tothe filament 120.

The filaments 120, 120′ can be any suitable suture material such as acannulated filament, a braided filament, and a mono filament. The type,size, and strength of the filament can depend, at least in part, on theother materials of the system, including the material(s) of any suturecoupled thereto, any obstructions through which the filament may pass,and the type of procedure in which it is used. In one exemplaryembodiment the filament is formed from a #0 filament (about 26 gauge toabout 27 gauge), such as an Orthocord™ filament that is commerciallyavailable from DePuy Mitek, Inc or Ethibond™ filament available fromEthicon, Inc. Generally the filament is relatively thin to minimize anytrauma to tissue through which it passes. In some embodiments thefilament can have a size between about a #4 filament (about 21 gauge toabout 22 gauge) and about a #4-0 filament (about 32 gauge to about 34gauge). The Orthocord™ #2 filament can be useful because it has abraided configuration, which allows other components, including thefilament itself and flexible members as discussed below, to pass throughsubcomponents of the braid without causing damage to the filament.Filaments configured to allow for a cannulated configuration, such as byremoving a core therefrom or having a pre-formed cannulatedconfiguration, can also be used. Orthocord™ suture is approximatelyfifty-five to sixty-five percent PDS™ polydioxanone, which isbioabsorbable, and the remaining thirty-five to forty-five percent ultrahigh molecular weight polyethylene, while Ethibond™ suture is primarilyhigh strength polyester. The amount and type of bioabsorbable material,if any, utilized in the filaments of the present disclosure is primarilya matter of surgeon preference for the particular surgical procedure tobe performed.

A length of the filament can be in the range of about 2 centimeters toabout 60 centimeters, and in one embodiment it can be about 40centimeters. Still further, a diameter of the sliding knot of the loopwill depend, at least in part, on the size of the filament used to formit, the type of sliding knot that it is, and the type of procedure withwhich it will be used. In one exemplary embodiment a diameter of thesliding knot of the loop can be in the range of about 0.5 millimeters toabout 2 millimeters, and in one embodiment it can be about 1 millimeter.Likewise, if the snare is formed from a sliding knot, its diameter willalso depend, at least in part, on the size of the filament used to formit, the type of sliding knot that it is, and the type of procedure withwhich it will be used.

Although in the embodiments described above the snare and collapsibleloop are formed from the same filament, in other embodiments eachcomponent can be formed from a separate filament. Exemplary systems,devices, and methods related to such configurations involving theformation of snares and loops from a single filament or more than onefilament are described at least in U.S. patent application Ser. No.13/218,810 filed Aug. 26, 2011, and entitled “SURGICAL FILAMENT SNAREASSEMBLIES,” and in U.S. patent application Ser. No. 13/465,288 filedconcurrently herewith, and entitled “Systems, Devices, and Methods forSecuring Tissue”, the content of each which is incorporated by referenceherein in its entirety.

Because the snare of the filament can both expand and contract, aflexible member, such as a suture pin, can be removably disposed acrossthe neck to prevent unintentional movement of the snare. One exemplaryembodiment of a flexible member 180″ associated with a coaxially slidingneck 155″ of a snare 150″ of a filament 120″ is shown in FIG. 6. Asillustrated, the flexible member 180″ can extend across the filament120″ to immobilize the coaxially sliding neck 155″ with respect to aportion 154″ of the filament 150″ through which it is passed. When thesurgeon desires to collapse the snare, the flexible member 180″ can beremoved. The use of a flexible member of the type described herein toprevent unintentional collapse of the snare in tissue repair proceduresis advantageous as it can prevent unintentional collapse of the snareduring the procedures, including in instances in which the snare ispassed through obstructions, such as tissue.

In another embodiment, shown in FIGS. 7A and 7B, a flexible member 180′″can immobilize a snare 150′″ of a filament and serve as a suture shuttleto guide the filament through obstructions, such as tissue, during thecourse of a procedure. As shown in FIG. 7A, a first end 182′″ of theflexible member 180′″ can be passed across the filament, including acannulated portion 154′″ and a coaxially sliding neck 155′″ of thefilament, so that a first portion of the flexible member 180′″ isdisposed through the coaxially sliding neck 155′″, while a second end184′″ of the flexible member 180′″ is passed through and disposed in thesnare 150′″. A protrusion 186′″, for instance a stationary knot that canbe pre-formed or formed or modified during a procedure, can be disposedon the flexible member 180′″ at a location between the first and secondends 182′″, 184′″. The protrusion 186′″ can serve to maintain theflexible member 180′″ in a coupled arrangement with the filament, and asshown in FIG. 7B, the protrusion 186′″ can be disposed within theopening or loop 152′″ formed by the snare 150′″, abutting a surface ofthe snare, with a terminal portion 188′″ extending through and beyondthe loop 152′″ for use as a shuttle. Optionally, a needle or similartool or device can be coupled to the terminal portion 188′″ to assist inthreading the filament 120′″ through tissue.

Other configurations in which a flexible member is used as both a suturepin and a suture shuttle are also possible, depending, at least in part,on the configuration of the filament and obstructions though which thefilament will be passed, without departing from the spirit of thepresent disclosure. For example, the flexible member 180′″ can bedisposed through another portion of the coaxially sliding neck 155′″ ora different portion of the snare 150′″. One benefit of using a flexiblemember for both maintaining a snare shape and shuttling the filament isthat it can improve filament management by limiting the number offilaments used in a procedure. Further, such a construction allows for asingle action to remove both the pin and the shuttle from the filament,such as by grabbing the flexible member 180′″ between the stationaryknot and the coaxially sliding neck 155′″ to decouple the flexiblemember 180′″ from the filament. In still other embodiments a flexiblemember can be used primarily for the purpose of shuttling the filamentand/or one flexible member can be used as a suture pin and a secondflexible member can be used as a suture shuttle.

The flexible member(s) can be made of a variety of materials, but in oneexemplary embodiment it is a surgical filament that is separate from thefilament that forms the snare and collapsible loop. In some embodimentsthe flexible member is formed using a surgical filament, such as acannulated filament, a braided filament, and a mono filament. The type,size, and strength of the filament can depend, at least in part, on theother materials of the system, including the material(s) of the filamentthrough which it will pass, the obstructions through which the snarewill pass, how the filament is being used (e.g., as a suture pin, as asuture shuttle, or as a joint suture pin and suture shuttle), and thetype of procedure in which it is used. In one exemplary embodiment theflexible member is formed from a #2-0 filament (about 28 gauge), such asan Orthocord™ filament that is commercially available from DePuy Mitek,Inc. or Ethibond™ filament available from Ethicon Inc. Generally theflexible member is relatively thin to minimize any trauma to tissuethrough which it passes, and typically the flexible member is thinnerthan filament through which it passes. In some embodiments the flexiblemember can have a size between about a #1 filament (about 25 gauge toabout 26 gauge) and about a #6-0 filament (about 38 gauge to about 40gauge). A length of the flexible member can be in the range of about 1centimeter to about 100 centimeters. In one embodiment in which theflexible member is only being used as a suture pin it can have a lengthof about 2 centimeters. In one embodiment in which the flexible memberis used as both a suture pin and a suture shuttle it can have a lengthof about 100 centimeters.

FIG. 8 illustrates one exemplary embodiment of a suture 70 for use aspart of the surgical repair construct 10. The suture is generally aflexible member having one or more stationary protrusions 72 formedtherein. The protrusions 72 can have a spaced-apart arrangement, can bepre-formed by the suture manufacturer, or alternatively, a surgeon canform one or more of the protrusions 72 in advance of or during asurgical procedure. Different spaced-apart arrangements can be used fordifferent procedures with the spaced-apart relationship being based, atleast in part, on the other components of the surgical repair construct10, the tissue(s) that will be coupled to the suture 70, and the type ofprocedure being performed. In the illustrated embodiment, there are fourprotrusions 72 approximately equidistant from each other, although anynumber of protrusions, including by way of non-limiting example six, inany form of spaced relationships can be used. The protrusions 72 can beused to assist in grasping soft tissue for repair to help prevent thecollapsed snare 50 of the filament 20 from backlashing and to provideadditional strength to the tissue-to-bone attachment.

One skilled in the art will appreciate that protrusions 72 can be formedby placing a knot in the suture 70, or by affixing another object to thesuture 70.

The suture can be made of any suitable suture material, such as acannulated filament, a braided filament, and a mono filament. The type,size, and strength of the filament can depend, at least in part, on theother materials of the system, including the material(s) of the filamentwith which it will be coupled, the tissue(s) through which the suturemay pass, and the type of procedure in which it is used. In oneexemplary embodiment the suture is formed from a size #2 (23-24 gauge)filament, such as an Orthocord™ filament that is commercially availablefrom DePuy Mitek, Inc. or Ethibond™ filament available from Ethicon,Inc. Generally the suture is relatively thin to minimize any trauma totissue through which it passes. In some embodiments the suture can havea size between about a #5 filament (about 20 gauge) and about a #4-0filament (about 32 gauge to about 34 gauge). A length of the suture canbe in the range of about 10 centimeters to about 120 centimeters, and inone embodiment the suture has a length of about 90 centimeters. Stillfurther, a diameter of the protrusions can be in the range of about 0.5millimeters to about 2 millimeters, and in one embodiment the diameterof each of the protrusions is about 1 millimeter. Additionally, a lengthof a space between each of the protrusions can be in the range of about1 millimeter to about 10 millimeters, and in one embodiment the lengthof the space between each protrusion is about 5 millimeters. Thediameters of the protrusions along a length of the suture and a lengthof a space between each of the protrusions can all be the same, or theycan vary from protrusion to protrusion.

One exemplary method for performing a rotator cuff repair using therepair construct 10 illustrated in FIG. 1 is schematically illustratedin FIGS. 9A-9E. A surgical opening can be formed through skin 104 and acannula can be passed therethrough to create a surgical repair site in amanner well known to those skilled in the art. Although cannulas areoften used to define a channel through which the procedure can beperformed, the cannula is not shown in FIGS. 9A-9E for ease ofillustration. Accordingly, to the extent the figures show components ofthe systems and devices passing through skin 104, these components wouldtypically be extending through the cannula, which itself is passedthrough the skin 104. Further, although the devices and methodsdescribed herein are particularly useful for minimally invasive surgery,such as arthroscopic surgery, they can also be used in open surgicalprocedures.

As shown in FIG. 9A, the suture 70 can be passed through a tendon 102detached from bone 100 such that at least one of the protrusions 72 isdisposed adjacent to at least one side of the tendon 102. In theillustrated embodiment, two protrusions 72 are located proximal of thetendon 102 while two protrusions 72 are disposed within the tendon 102.Although not shown, it is understood that one or more protrusions can beformed on the distal side of the tendon 102, as opposed to within it.The suture 70 can be passed completely or partially through the tissueusing any number of techniques known to those skilled in the art,including by coupling a needle or similar tool or device to one ofterminal ends 74 of the suture 70 to assist with threading the suture 70through the tendon 102. In one exemplary embodiment, one of the terminalends 74 is passed through the tendon 102 from a first (proximal) side ofthe tendon 102 facing away from the adjacent bone 100 and back throughthe tissue from a second (distal) side of the tendon 102 facing towardsthe bone 100 such that first and second limbs 76, 78 of the suture 70extend from the first side of the tendon 102, i.e., proximal of thetendon 102. The suture 70 can be manipulated by a surgeon with respectto the tendon 102 to expose as many protrusions 72 as desired.Protrusions 72 located proximal of and adjacent to the tendon 102 can beused to help maintain a location of the collapsed snare 50 as well as toaccommodate variations in tissue thickness and the bite size (i.e., thedistance between the locations that the suture limbs enter the tissue).In one embodiment it is particularly useful to have at least twofully-exposed protrusions in close proximity to the tendon 102. A personskilled in the art will recognize that there are other ways by which thesuture 70 can be coupled to or shuttled through the tendon 102,including, by way of non-limiting example, by wrapping the suture 70around the tendon 102 such that at least one of the protrusions 72 isproximal of the tendon 102. Further, the suture can be passed throughtissue (e.g., tendon 102) through a variety of techniques andorientations known to those skilled in the art.

As shown in FIG. 9B, the anchor 90 can be fixated into bone 100 usingordinary techniques, such as with a driver to screw or tap the anchor 90into place. In the illustrated embodiment the filament 20 is alreadycoupled thereto at the engagement feature 92, although in otherembodiments the filament 20 can be slidingly coupled to the anchor 90after the anchor 90 is positioned at its desired location. As shown, thefilament 20 includes the snare 50, the collapsible loop 30, the slidingknot 36, and the collapsible tail or tensioning limb 40.

As shown in FIG. 9C, the terminal ends 74 of the first and second limbs76, 78 of suture 70 can be passed through the opening 52 of the snare50, thereby placing the tendon 102 in a position to be coupled to thefilament 20. The snare 50 can then be advanced distally towards the bone100, for instance by sliding the snare 50 along the suture 70, until thesnare 50 is distal of at least one of the protrusions 72 and proximal ofthe tendon 102. As shown in FIG. 9D, the snare 50 can be advanced distalof two protrusions 72 and is located approximately adjacent to thetendon 102. In other embodiments the snare 50 can be advanced distal ofthree or more protrusions 72. Any number of techniques known to thoseskilled in the art can be used to advance the snare 50 distally,including using a pusher tool or advancing it by hand.

After the snare 50 has been advanced distally past at least one of theprotrusions 72 and to its desired location, the snare 50 can becollapsed or dressed in a manner consistent with its snare type.Collapsing the snare 50 around the suture couples the tendon 102 to thefilament 20 and directs it towards the bone 100. In some embodiments, aflexible member can be disposed through the snare 50 to preventunintentional collapse of the snare opening 52. In such embodiments, theflexible member can be removed prior to collapsing or dressing thesnare. Further, although in the illustrated embodiment the snare 50 iscollapsed after it is advanced distally past at least one of theprotrusions 72, in other embodiments the snare 50 can be at leastpartially collapsed prior to fully advancing it in the distal directionprovided that the opening 52 in the snare 50 is still configured toallow at least one of the protrusions 72 to pass therethrough.

As shown in FIG. 9E, tension can be applied to the tensioning limb 40 bypulling approximately in a direction D, thereby causing the sliding knot36 to advance distally towards the bone 100 to decrease a size of theopening 38 of the collapsible loop 30, i.e., shorten the collapsibleloop 30. This movement also applies additional tension to the suture 70by virtue of being coupled to the filament 20, and in turn brings thetendon 102 into proximity with the bone 100. The configuration of thefilament 20 in conjunction with the suture 70 allows the knot 36 to beadvanced in an incremental, ratchet-like fashion when the tensioninglimb 40 is pulled in the direction D without the risk of reversing theprogress of the knot 36 as a result of slipping backward, sometimesreferred to as backing out, backlashing, or slackening of the filament.Optionally, as shown, excess portions of the terminal ends 74 of thesuture 70 proximal of the protrusions 72 can be cut-off and removed.Likewise, an excess portion of the tensioning limb 40 can also becut-off and removed if desired. In embodiments in which the filamentincludes a stationary terminal tail or limb adjacent to the tensioninglimb, excess portions of that limb can likewise be cut-off and removedif desired. Still further, optionally, one or more half-hitches can beadded to the filament 20, for instance on the tensioning limb 40, thesuture 70, or a stationary terminal limb if such limb exists, to provideadditional strength once the filament 20 and suture 70 have been finallypositioned to approximate tissue. Other than the optional half-hitches,no knots need to be tied during the course of the illustrated procedure.

The resulting break strength of the formed attachment can be in therange of about 50 Newtons to about 200 Newtons without the formation ofany half-hitches, and in one embodiment the break strength can be about130 Newtons without the formation of any half-hitches. The use ofhalf-hitches typically increases the load capacity.

The procedure discussed with respect to FIGS. 9A-9E is just one exampleof a procedure that can be performed in conjunction with systems,devices, and methods disclosed herein. A person skilled in the art willrecognize a number of other ways that the disclosed systems, devices,and methods can be used in various other configurations and types ofsurgical procedures. For example, although the filament 20 of FIGS.9A-9E is coupled to an anchor, in other embodiments, no anchor can beused and instead repair constructs of the nature disclosed herein can becoupled directly to bone without an anchor. Alternatively, repairconstructs of the nature disclosed herein can be used to draw two ormore tissues together by passing a filament of a construct through onetissue, a suture having one or more stationary protrusions formedthereon through a second tissue, and the operating the construct in amanner consistent with the teachings herein. Further, the systems,devices, and methods can easily be adapted to be used in conjunctionwith three or more components, such as multiple tissues and a bone orthree or more soft tissue components. Some non-limiting examples ofother systems, devices, assemblies, constructs, and surgical procedureswith which the present systems, devices, and methods can be used aredescribed in U.S. patent application Ser. No. 13/218,810 filed Aug. 26,2011, and entitled “SURGICAL FILAMENT SNARE ASSEMBLIES,” and in U.S.patent application Ser. No. 13/465,288 filed concurrently herewith, andentitled “Systems, Devices, and Methods for Securing Tissue”, thecontent of which was previously incorporated by reference herein intheir entireties.

One skilled in the art will appreciate further features and advantagesof the invention based on the above-described embodiments. Accordingly,the invention is not to be limited by what has been particularly shownand described, except as indicated by the appended claims. By way ofnon-limiting example, although the embodiments described herein includea snare formed in a first end of the filament, other components havingsimilar functionality can be associated with the first end of thefilament, such as a clip or a like element to clamp a portion of thesuture. Further, although the systems, devices, and methods provided forherein are generally directed to surgical techniques, at least some ofthe systems, devices, and methods can be used in applications outside ofthe surgical field. All publications and references cited herein areexpressly incorporated herein by reference in their entirety.

What is claimed is:
 1. A surgical repair method, comprising: passingthrough detached soft tissue a first end of a suture having formedthereon a plurality of stationary protrusions, the first end of thesuture being passed through the tissue such that first and second limbsof the suture extend from the first side of the tissue, the suture beingarranged in tissue such that at least one of the protrusions is disposedadjacent to at least one of the first and second sides of the tissue;inserting an anchor into bone in proximity to detached soft tissue, theanchor having attached to a filament engagement feature thereof afilament, the filament having a collapsible snare formed on one endthereof and a collapsible loop at a second end thereof and coupled tothe filament engagement feature, the collapsible loop including asliding knot with a tensioning limb extending therefrom and effective tocollapse the collapsible loop independent of the snare; inserting thefirst and second limbs of the suture through an opening formed in thesnare; sliding the snare distally towards the tissue and distally pastat least one protrusion disposed on the first side of the tissue;collapsing the snare around the first and second limbs of the suture;and pulling the snare towards the anchor by shortening the collapsibleloop and drawing the tissue into proximity with the bone.
 2. The methodof claim 1, wherein the step of pulling the snare towards the anchor byshortening the collapsible loop comprises tensioning the tensioninglimb.
 3. The method of claim 2, wherein the snare is advanced in anincremental fashion without slackening of the filament.
 4. The method ofclaim 1, wherein the suture includes at least four protrusions.
 5. Themethod of claim 4, wherein the snare is positioned between at least oneprotrusion and the tissue.
 6. The method of claim 4, wherein the snareis positioned between at least two protrusions and the tissue.
 7. Themethod of claim 1, wherein a flexible member is disposed in a portion ofthe snare to prevent unintentional collapse thereof, the method furthercomprising removing the flexible member from the snare prior tocollapsing the snare.
 8. The method of claim 1, wherein the method isperformed without tying a knot.